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EXAM 2 > Renal 9.5 > Flashcards

Renal 9.5 Flashcards

1
Q

HIV can lead to what cause of nephrotic syndrome?

A

FSGS

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2
Q

Nephrotic syndrome that presents in young adults that has a high occurrence rate in renal Tx?

A

FSGS

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3
Q

Causes of FSGS?

A 
idiopathic
2ry to other renal pathology e.g. IgA nephropathy, reflux
HIV
heroin
Alport's
sickle-cell
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4
Q

Chronic analgesia use causes what type of kidney disease?

A

Tubulo-interstitial nephritis & papillary necrosis

  • sloughing of papillae can result un urinary tract obstruction ->AoCKI
  • can have a salt-losing nephropathy
  • eg clubbed calyces & ring signs on IV urogram
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5
Q

Papillary necrosis

  • causes?
  • features?
A
  • chronic analgesia
  • sickle cell
  • TB
  • acute pyelonephritis
  • DM
  • fever, loin pain, haematuria
  • IV urogram: ‘cup & spill’ papillary necrosis with renal scarring
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6
Q

Diabetic nephropathy

  • Ix?
  • Rx?
A
  • urinary ACR annually - early morning specimen
  • if ACR >2.5 then microalbuminuria
  • restrict dietary protein, tight glycaemic control, aim BP <130/80, control dyslipidaemia
  • ACE-I is reno-protective (a decrease in eGFR up to 25% or a rise in Cr up to 30% is acceptable)
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7
Q

Causes of UL hydronephrosis?

PACT

A

Pelvic-ureteric obstruction (congenital/acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis

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8
Q

Causes of BL hydronephrosis?

SUPER

A 
Stenosis of urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retroperitoneal fibrosis
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9
Q

Ix of hydronephrosis:
1st line?
to assess position of obstruction?
to allow Rx?

A
  • 1st US KUB
  • IV urogram assesses position of obstruction
  • anterograde/retrograde Pyelography allows Rx
  • CT if suspected renal colic
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10
Q

Rx of hydronephrosis?
if acute
if chronic

A
  • remove obstruction & drain urine
  • acute upper: nephrostomy
  • chronic upper: ureteric stent or pyeloplasty
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11
Q

2 types of peritoneal dialysis?

A

CAPD: continuous ambulatory PD - each exchange lasts 30-40mins, each dwell time lasts 4-8h
APD: automated PD - dialysis machine fills & drains abdomen while pt is sleeping, performing 3-5 exchanges over 8-10h each night

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12
Q

Renal Tx - where are the renal donor vessels connected to?

A

Connected to external iliac vessels

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13
Q

Complications of peritoneal dialysis?

A
  • peritonitis, sclerosing peritonitis
  • catheter infection/blockage
  • constipation, fluid retention
  • hernias, back pain
  • malnutrition, hyperglycaemia
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14
Q

Complications of haemodialysis?

A
  • site infection/stenosis
  • endocarditis
  • hypotension, cardiac arrhythmia, air embolus
  • anaphylaxis reaction to sterilising agents
  • disequilibration syndrome
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15
Q

Complications of renal Tx?

A
  • opportunistic infection, BM suppression, malignancy esp lymphoma/skin cancer
  • DVT/PE
  • urinary tract obstruction
  • CVD
  • recurrence in graft
  • graft rejection
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16
Q

Average life expectance of a pt with renal failure that doesn’t receive RRT is 6months.
What are the Sx not being adequately managed with RRT ?

A
  • SOB, fatigue
  • insomnia, anxiety, depression
  • weakness, poor apposite, swelling, weight gain/loss
  • nausea, abdo cramps, muscle cramps, headaches, cognitive impairment
  • sexual dysfunction
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17
Q

HLA = MHC in humans on chr 6

  • what are the class 1 & 2 Ag?
  • what is the important when matching for a renal Tx?
A 
class 1 = A, B, C
class 2 = DP, DQ, DR

DR > B > A

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18
Q

Post-op problems in renal Tx?

A

ATN of graft
vascular thrombosis
urine leakage
UTI

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19
Q

Hyperacute rejection of renal Tx?

A
  • due to pre-existing Ab againts donor HLA type 1 Ag (type II hypersens)
  • mins-hours
  • rare due to HLA matching
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20
Q

Acute graft failure of renal Tx?

A
  • due to mismatched HLA (cell-mediated by cytotoxic T cells)
  • or CMV infection
  • within 6months
  • may be reversible with steroids & immunosuppressants
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21
Q

causes of chronic graft failure with renal Tx?

A
  • Ab & cell-mediated mechanisms cause fibrosis to Tx kidney (chronic allograft nephropathy)
  • recurrence of original disease: MCGN > IgA > FSGS
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22
Q

Which diseases tend to recur in kidney Tx graft?

A

MCGN > IgA > FSGS

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23
Q

Rhabdomyolysis

  • causes?
  • features?
  • Rx?
A
  • seizure, collapse, coma
  • ecstasy
  • crush injury
  • McArdle’s syndrome
  • drugs: statins esp if co-Px with clarithromycin
  • AKI with disproportionately raised Cr
  • high CK
  • myoglobinuria
  • low Ca2+ (myoglobin binds Ca2+)
  • high phosphate (released from myocytes_
  • high K (may develop before renal failure)
  • metabolic acidosis
  • IV fluids, maintain good urine output
  • sometimes urinary alkalinisation
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24
Q

Tests for determining a patient’s iron status and thus response to treatment in CKD?

A
  • %hypochromic red cells (analysis within 6h) - >6% indicates iron deficiency
  • reticulocyte Hb <29 is Dx of IDA
  • combo of transferrin sat <20% & ferritin <100
    (keep ferritin <800, change iron dose if >500)
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25
Q

When does anaemia in CKD become apparent?
Causes?
What does it predispose to?
Rx?

A
  • eGFR <35
  • predisposes to LV hypertrophy -> 3X inc risk in mortality
  • reduced EPO biggest factor
  • reduced erythropoiesis due to toxic effects of uraemia on BM
  • reduced iron absorption
  • anorexia/nausea due to uraemia
  • reduced red cell survival esp in HD
  • blood loss due to capillary fragility & poor platelet function
  • stress ulceration -> chronic blood loss
  • target Hb 10-12
  • determine & optimise iron status before starting an ESA: erythropoiesis-stimulating agent (many will require IV iron)
  • EPO/Darbepoetin should be used in those who are likely to benefit in terms of QoL & physical function
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26
Q

Alport’s syndrome = inherited X-linked dominant defect in gene shich codes for type IV collagen -> abnormal GBM

  • more severe in males (ESRF)
  • usually presents in childhood
  • features?
A

renal: microscopic haematuria, progressive renal failure
eye: retinitis pigments, lenticonus: protrusion of lens surface into anterior chamber
ear: BL SNHL
renal Bx: SPLITTING of lamina densa seen on EM

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27
Q

Alport’s syndrome pt receives a renal Tx. It startsto fail. What is the Dx?

A

Goodpasture’s syndrome due to presence of anti-GBM Ab

- immune response to the type IV collagen in the Tx kidneys

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28
Q

ADPKD features?

extra-renal manifestations?

A
  • HTN
  • rec UTIs, renal stones, abdo pain, haematuria
  • CKD
  • liver cysts 70%
  • berry aneurysms 8% can rupture -> SAH
  • CVS: MVP, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
  • other cysts: pancreas spleen
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29
Q

Potential complications of AV fistulas?

A

infection
thrombosis
stenosis
steal syndrome

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30
Q

Prevention of stones due to hypercalciuria e.g. calcium phosphate?

A

Thiazide

high fluid intake, low animal protein, low salt diet

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31
Q

Drug useful in prevention of calcium oxalate stones?

A

Potassium citrate
Cholestyramine
Pyridoxine

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32
Q

Drug useful in prevention of uric acid stones?

A

Allopurinol

oral bicarb

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33
Q

Dx Ix for renal stone?

A

Non-contrast CT KUB within 14h

- immediate if fever, solitary kidney or when Dx uncertain - to exclude other Dx

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34
Q

Rx for ureteric obstruction 2ry to a stone, WITH infection?

A

Emergency decompressive surgery

  • nephrostomy tube
  • ureteric catheter insertion
  • ureteric stent
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35
Q

Shockwave lithotripsy for renal stone

  • risk?
  • when is it used?
A
  • shock waves can cause solid organ injury
  • fragmentation of larger stones can cause obstruction
  • uncomfortable for pt
  • stone burden <2cm
36
Q

retrograde Ureteroscopy for renal stone

- when is it used?

A
  • retrograde through ureter into renal pelvis
  • indicated when lithotripsy C/I e.g. pregnancy or complex stone disease
  • usually stent left in situ 4wks post-procedure
  • i.e. stone burden <2cm
37
Q

Percutaneous nephrolithotomy for renal stone Rx

  • how?
  • when is it used?
A
  • access to renal collecting system, then intra-corporeal lithotripsy/stone fragmentation & stone fragments removed
  • complex renal stones or stag horn
38
Q

Rfs for contrast media toxicity?

Definition?

A

25% increase in Cr occurring within 3 days of intravascular administration of contrast media

  • known renal impairment esp diabetic nephropathy
  • age >70
  • dehydration
  • cardiac failure
  • nephrotoxics eg NSAIDs
  • prevention: IV 0.9% NaCl at 1 mL/kg/h for 12h pre- & post- procedure
39
Q

Renal Stones formed from triple Mg, ammonium & phos

  • Urease-producing bacteria (therefore ass with chronic infections) e.g. proteus, klebsiella, mycoplasma
  • pH >7.2 alkaline conditions, the crystals can precipitate
  • Slightly radio-opaque
A

Struvite
pH >7.2
hypercalcamia is a RF
F>M

40
Q

85% of renal stones

  • hypercalciuria major RF, also hyperoxaluria & hypocitraturia
  • radio-opaque stones
A

Calcium oxalate

41
Q

10% of renal stones that may occur in RTA 1

  • high urinary pH increases supersaturation of urine
  • radio-opaque
A

Calcium phosphate

42
Q

1% of renal stones inherited recessive disorder of transmembrane cystine transport

  • decreased cystine absorption from bowel & renal tubule
  • multiple stones may form
  • relatively radio dense (contain sulfur)
A

Cystine

43
Q

5-10% of renal stones that may precipitate when urinary pH low

  • can be caused by diseases of extensive tissue breakdown e.g. malignancy - product of purine metabolism
  • more common in children with inborn errors of metabolism
  • radiolucent
A

Uric acid

44
Q

Urinary pH in helping determine renal stone type

A

Urine pH 5-7 - falls post-prandially as purine metabolism produces uric acid - then alkaline tide

pH 5.5 acid - uric acid
pH >5.5 in normal/alkaline calcium phosphate
pH 6 variable calcium oxalate
pH 6.5 normal cystine
pH >7.2 alkaline struvate
45
Q

Retroperitoneal fibrosis

  • commonest PC?
  • associations?
A
  • lower back/flank pain
  • also fever & LL oedema
  • Riedel’s thyroiditus
  • previous RT
  • sarcoid
  • inflammatory AAA
  • drugs e.g. methysergide, bromocriptine
46
Q

Absolute C/I to being an LRD kidney donor?

A
  • uncontrolled BP/on 3 anti-hypertensives (nephrectomy can exacerbate HTN)
  • active cancer
  • chronic infection
  • over proteinuria
  • BL renal artery atherosclerosis
  • sickle cell disease
47
Q

ADPKD type 1 85%

  • which chr
  • difference with ADPKD type 2
A

chr 16
presents with renal failure earlier
(type 2 chr 4)

48
Q

US Abdo Dx criteria on screening family for ADPKD?

A
  • 2 cysts UL/BL age <30
  • 2cysts in both aged 30-59
  • 4 cysts in both aged >60
49
Q

Rx of ADPKD?

A

TOLVAPTAN can slow progression of cyst development & renal insufficiency if:

  • CKD stage 2/3 at the start
  • evidence of rapidly progressing disease
  • discount for pt
50
Q

Renal involvement in HIV?

A
  • Rx or virus itself
  • PIs eg INDINAVIR can precipitate intratubular crystal obstruction - ie crystalise in urine and cause renal stones - microscopy shows needle-shaped crystals
51
Q

HIVAN: HIV ass nephropathy

  • 5 features?
  • Rx?
A
  • raised Ur & Cr
  • massive proteinuria -> nephrotic
  • normal/large kidneys
  • FSGS with focal/global capillary collapse on renal Bx
  • normotension

Antiretrovirals can alter course of disease

52
Q

Pt with HIV: a collapsing FSGS and presents with nephrotic syndrome

A

HIVAN

53
Q

Pt with HIV presents with nephritic syndrome

A

HIV-associated immune complex kidney disease (HIVICK)

54
Q

HIV on Rx: develops acute tubular necrosis / Falcon syndrome - cause?

A

Tenofovir

55
Q

mesangiocapillary glomerulonephritis = membranoproliferative GN
- how does it present?

A 
nephrotic
haematuria
or proteinuria
poor prognosis
rx = steroids may help
56
Q

Type 1 mesangiocapillary glomerulonephritis = membranoproliferative GN?

A

90%

  • cryoglobulinaemia, hepatitis C
  • sub endothelial immune deposits of electron dense material - tram-track
57
Q

Type 2 mesangiocapillary glomerulonephritis = membranoproliferative GN?

A

dense deposit disease

  • reduced complement
  • C3b nephritic factor in 70%
  • partial lipodystrophy, factor H deficiency
58
Q

Type 3 mesangiocapillary glomerulonephritis = membranoproliferative GN causes?

A

hepatitis B &C

59
Q

Pre-Renal Uraemia: kidneys hold on to sodium to preserve volume
- what is in the urine?

A
  • bland sediment
  • specific gravity >1020
  • urine:plasma urea >10:1
    urine: plasma osmolality >1.5
  • fractional urea excretion <35%
  • fractional sodium excretion <1%
  • urine sodium <20
60
Q

Acute tubular necrosis

  • does it respond to fluid challenge?
  • what is in the urine?
A
  • No
  • urine sodium >30
  • fractional sodium excretion >1%
  • fractional urea excretion >35%
  • urine:plasma osmolality <1.1
  • urine:plasma urea <8.1
  • SG <1010
  • urine BROWN GRANULAR CASTS
61
Q

Goodpasture’s syndrome: pulmonary haemorrhage & rapidly progressive glomerulonephritis

  • anti-GBM against type IV collagen
  • ass with HLA DR2
  • factors increasing likelihood of pulmonary haemorrhage?
  • Ix?
  • Rx?
A
  • smoking, LRTI, pulmonary oedema, inhalation of hydrocarbons, young males
  • real Bx: linear IgG deposits along BM
  • raised transfer factor 2ry to pulmonary haemorrhages
  • Rx = plasma exchange/plasmapheresis; steroids, cyclophosphamide
62
Q

post-transplant lymphoproliferative disorder

A
  • clonal populations of T/B cells in significant lymphoid disruption of renal architecture
  • EBV Ag with Ig light chain expression
63
Q

Declining renal function in myeloma - what stain on renal Bx for an ass complication?

A

Congo red

- 2ry amyloid AL

64
Q

AL myloid = 2ry = commonest

  • Ig light chain
  • causes?
  • features?
A

myeloma, MGUS, Waldenstrom’s

- nephrotic syndrome, cardiac & neuro involvement, macroglossia, periorbital eccymoses

65
Q

AA amyloid = 1ry = serum amyloid A acute phase reactant protein

  • cause?
  • features?
A
  • chronic infection/inflammation eg TB, RA, bronchiectasis

- fenal involvement commonest feature

66
Q

Beta-2 microglobulin amyloidosis

- association?

A
  • pts on renal dialysis

- precursor protein is beta-2 microglobulin, part of MHC

67
Q

causes of cranial diabetes insipidus?

A 
idiopathic, post-head injury
pituitary surgery
craniopharyngiomas
histiocytosis X
DIDMOAD
68
Q

Causes of nephrogenic DI?

A

genetic (ADH receptor)
high Ca, low K
demeclocycline, lithium
tubulo-interstitial disease: obstruction, sickle cell, pyelonephritis

69
Q

Ix of diabetes insipidus?

A
  • high plasma osmolality, low urine osmolality
  • urine osmolality >700
  • water deprivation test
70
Q

Post-strep GN day7-14 after

  • caused by immune complex deposition in glomeruli
  • clinical features?
  • renal Bx features?
A
  • headache, malaise, haematuria, proteinuria, HTN, low C3, raised ASO titre
71
Q

Ix for renal vascular disease?

causes?

A

young: fibromuscular dysplasia - string of beads on angiography - pts respond well to balloon angioplasty
otherwise commonly atherosclerosis - can present as HTN, CKD, flash pulmonary oedema

Ix = MR angiography
(CT angio or renal agio may help plan surgery)

72
Q

Rx of diabetes insipidus?

A

Thiazide diuretic or NSAIDs
- Diuretics act to induce hypovolaemia leading to a subsequent increase in proximal Na & water reabsorption, thereby diminishing the water delivery to the ADH sensitive sites in the collecting tubules, and reducing the urine output.

73
Q

Complications of nephrotic syndrome

A
  • inc risk infection due to urine Ig loss
  • inc risk thromboembolism (antithrombin III & plasminogen in urine) - can cause renal vein thrombosis i.e. sudden deterioration in renal function
  • hyperlipidaemia
  • hypocalcaemia
  • acute renal failure
74
Q

Triad of haemolytic uraemia syndrome?
Typical HUS?
atypical/1ry?

A

acute renal failure
MAHA
thrombocytopenia

Typical:
- E. coli 90%, pneumococcal, HIV, SLE, drugs, cancer

1ry = atypical = due to complement dysregulation

Ix: anaemia, low platelets, fragmented blood film, AKI, do stool culture

Rx = supportive

  • plasma exchange if severe and not ass with diarrhoea
  • ECULIZUMAB = C5 inhibitor mAb better than plasma exchange in adult ATYPICAL HUS
75
Q 
Membranous GN = commonest type of GN in adults - usually presents with nephrotic syndrome &amp; proteinuria
Renal Bx?
Causes?
Prognosis?
good prognostic features?
Rx?
A
  • EM: thickened basement membrane with sub epithelial electron dense deposits -> Spike & dome appearance
  • idiopathic anti-phospholipase A2 Ab
  • hep B, malaria, syphilis
  • lung ca, lymphoma, leukaemia
  • gold, penicillamine, NSAIDs
  • SLE class V, thyroiditis, rheumatoid
  • 1/3 spontaneous remission, 1/3 remain proteinuric, 1/3 ESRF
  • good Px features: female, young, aSx proteinuria

Rx:

  • immunosuppressants steroid + other
  • control BP
  • consider anticoagulation
76
Q

Normal anion gap acidosis causes?

A 
GI loss
RTA
acetazolamide
ammonium Cl injection
Addisons
77
Q

Causes of polyuria?

A

common - diuretics, caffeine, ETOH, DM, lithium, heart failure
infrequent - high Ca, hyperthyroid
rare - CKD, 1ry polydipsia, low K
v rare - diabetes insipidus

78
Q

Fanconi syndrome = generalised disorder of renal tubular transport in pct

  • what does it lead to?
  • what are the causes?
A
  • T2 proximal RTA
  • polyuria
  • aminoaciduria
  • glycosuria
  • phosphaturia
  • osteomalacia
  • cystinosis
  • Sjogren’s
  • myeloma
  • nephrotic syndrome
  • WIlson’s disease
79
Q

Cystinuria = rec stones that present in first decades of life
Dx?

A

sodium nitroprusside test

can be +ve with generalised aminoaciduria

80
Q 
Minimal change disease - nephrotic syndrome
Causes?
Pathphys?
Features?
Rx?
A
  • majority idiopathic
  • also NSAIDs, rifampicin, Hodgkin’s lymphoma, thymoma, infectious mononucleosis
  • Tcell & cytokine mediated damage to glomerular BM -> pollination loss -> reduction of electrostatic charge -> increased glomerular permeability to serum albumin
  • nephrotic syndrome, normotension, highly selective proteinuria
  • EM shows fusion of podocytes on renal Bx
  • 80% steroid-responsive
  • next step is cyclophosphamide
81
Q

Factors favouring organic cause of erectile dysfunction?

A
  • gradual onset of Sx
  • lack of tumescence
  • normal libido
82
Q

Factors favouring psychogenic cause of erectile dysfunction?

A
  • sudden onset Sx, decreased libido
  • good quality spontaneous/self-timulated erections
  • major life event, problems in relationship/change, prev psych problems
  • Hx of prem ejaculation
83
Q

RFs for ED?

A

CVD RFs
ETOH
SSRIs, beta-blockers

84
Q

Ix & Rx for ED?

A
  • CV risk lipids, glucose
  • 9-11am free testosterone, if low/borderline then repeat with FSH, LH & PRL
  • PDE-5 inhibitor in absence of C/I
  • vacuum erection device
85
Q

Testosterone replacement in deficiency?

A

If elevated PSA, male breast ca, prostate ca, severe sleep apnoea or severe LUTS then cannot have testosterone

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